THE BENEFITS OF A PUBLIC ACCESS DEFIBRILLATION PROGRAM
MICHAEL A. KONOZA
BS (EMS), NREMT-P
Sudden cardiac arrest (SCA) affects 1,000 United States citizens every day. Ninety-five percent of these victims die1 of ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT).2 Defibrillation can reverse SCA if delivered within a 10-minute window. The American Heart Association (AHA) four-link chain of survival, adopted in 1990, consists of the following: (1) early access–911, (2) early cardiopulmonary resuscitation (CPR), (3) early defibrillation, and (4) advanced cardiac life support (ACLS).[2]
The AHA, the American College of Emergency Physicians (ACEP), the National Association of EMS Physicians, the Citizen CPR Foundation, and the International Association of Fire Chiefs (IAFC) believe that public access defibrillation (PAD) using automatic external defibrillators is the way of the future in providing this vital third link in the chain within the right amount of time.[2]3
ACEP`s EMS Committee4,5 recommends the implementation of AED programs countrywide.6 According to the AHA, for every minute that an SCA patient goes without defibrillation, the chance of survival decreases by 10 percent, thus the 10-minute window. Although fire and EMS agencies strive for response times of four to five minutes or better, reported patient downtime to “with patient” (call-to-shock) time can easily be more than 10 minutes. Because of this, AEDs have to become synonymous with first aid and CPR training, thus forming PAD programs. The AHA has estimated that PAD programs can prevent at least 20,000 deaths each year.7 Since January 1998, AEDs have already been incorporated into AHA and National Safety Council CPR classes for health professionals (doctors, nurses, and technicians) and can be an add-on to a first aid class.8
According to the International Association of Fire Chiefs, only 34.2 percent of fire departments used AEDs in 1997.9 Even so, the use of defibrillators should not be limited to use by firefighter/ EMTs and paramedics. Police officers patrolling neighborhoods are good candidates for training. An ACEP study from the Mayo Clinic calls for placing AEDs inside police cruisers.[1]
In the public sector, a University of Washington study looked at security guards to provide AED service because of the high rates of cardiac arrest found in shopping malls, on golf courses, and in casinos.[1] EMP America, a private company engaged in CPR and first aid training, recommends that AEDs be placed in gathering places of more than 10,000 people.10 Other good target locations are large high-rise buildings and airlines.
The USA Today building in Arlington, Virginia, has purchased an AED and trained its security officers to use it. The building is 33 stories high and requires the transfer from one bank of elevators to another to access the upper floors. This has greatly increased the estimated call-to-shock time for EMS. Now, a defibrillator definitely can be there at any patient`s side within 10 minutes regardless of what floor the patient is on.
Industrial EMS teams (such as Kimberly-Clark, DuPont, and Scott Paper) use semiautomatic AEDs.11 Fully automatic AEDs are most suitable for lay people with little or no medical training. Semiautomatic AEDs, which require some decision making on the part of the user, are most suitable for medical teams. Although research in 1991showed fully automatic AEDs to be better even for EMS use12, it is now a moot point based on more recent data. The risks involved with civilian use of AEDs are low, but the benefits are very high.13 Training of the lay public would result in a public access defibrillation program in the truest sense of the word.
Because of the increased survival rate associated with improved call-to-shock times, health department nurses who staff elder care centers (especially those with long waits for EMS) are prime candidates for training. So, excellent places for AEDs would be geriatric clinics, nursing homes, and retirement homes.
LAWS AND LITIGATION
The advent of the AED requires that laws be updated to include this new technology. The Public Access Defibrillation League lists about 15 states that have PAD-friendly legislation. New Hampshire and Rhode Island do not need additional legislation: Their Good Samaritan Acts already provide a large enough umbrella of immunity for rescuers using AEDs, whether they be public safety or civilian. In July 1997, Nevada enacted a new Good Samaritan law that protects trained users of AEDs from liability.[8]
The California Code of Regulations has specific training standards for “nonlicensed or noncertified” personnel.14 The District of Columbia also has adopted guidelines.[1] The Commonwealth of Virginia requires an Operational Medical Director (OMD) to oversee AED/PAD programs. This regulation is hampering the increased growth of additional AED programs in that state.
More states need to develop Good Samaritan-type legislation. About 15 states are considering this type of legislation for the 1999 session. The remaining 20 states either have no PAD activity or are determining the need for such legislation.
On the federal level, the Cardiac Arrest Survival Act of 1999 (CASA), which was not acted on in the last session of Congress, was to be reintroduced around press time by Senator Slade Gorton (WA) and Representative Cliff Stearns (FL). The proposed legislation has two objectives, according to the Congressional Fire Services Institute (see News in Brief, Fire Engineering, September 1999). The first is to provide greater access to AEDs in federal buildings (sites to be designated by the Secretary of Health and Human Services), and the second, to remove civil liability for anyone who uses the device to provide emergency medical care. The exemptions would apply also to those who acquire, maintain, and test the devices; train on their use; and provide medical oversight (physician). In effect, CASA would extend Good Samaritan acts nationally[8]; such broad-based legislation would make it much easier for PAD programs to be implemented.
Two recent court cases support AEDs and PAD programs. Busch Gardens of Florida was found negligent in part for failing to have a defibrillator on hand. The plaintiff in the case was awarded $500,000 in the death of her teenage daughter.
Lufthansa Airlines was found negligent for failing to provide “timely treatment” to a passenger who suffered a cardiac emergency. In this case, the plaintiff was awarded $2.7 million. As a result, numerous U.S. companies have become AED customers (Texas Instruments; USX Corporation; Ford Motor Company; Medtronics; Caterpillar, Incorporated; Komatsu; Allison Engine Company; Chicago`s United Center; the Chicago Bulls professional basketball team; the John Hancock Building in Boston; and American Airlines).[8]
TRAINING AND EDUCATION
The AED is not part of Emergency Medical Technician-Basic (EMT-B) training in some states.[1] It has been part of the Virginia State EMT-B program since 1995. It was made an option for individual states as part of the 1994 Department of Transportation (DOT) National Standard Curriculum (NSC) for EMT-B. At least 35 states require adherence to the DOT curriculum.
The AHA would prefer that all EMTs everywhere be required to have AED training. It also is a major proponent of PAD programs. Once all AHA Healthcare Provider CPR students are taught AED, the push will be for adding it to all AHA Heartsaver (layperson) CPR training. Skills training is on hold until improved legislation is passed, but the didactic component has been in use.
PAD programs should contain four components: (1) informing the lay public about the safety and efficacy of the AED, (2) educating the public in using the devices, (3) universal precautions and body substance isolation (BSI), and (4) equipment maintenance and placement. Fire and police departments teach anywhere from two to 10 hours of AED as part of first responder or EMT training.[9] The Clark County (Las Vegas) Fire Department uses a five-hour training program for its PAD program.[1] EMP America`s AED training course involves an overview of VF and AEDs, several scenarios (shock and no-shock training is most imperative) and demonstrations with a great deal of hands-on practice for the students. They recommend that all public safety units that perform CPR/first aid be equipped with AEDs and trained to operate them.[10]
EVOLUTION OF AEDs
The first AED was fully automatic and built in 1986.[1] Arlington County (VA) Fire Department`s first AEDs (semiautomatic) were placed in service in 1991. Other fire/EMS organizations began using them in the late 1980s and early 1990s. In 1995, the Federal Drug Administration (FDA) had some concerns about the safety of certain models of AEDs. Their concerns were unfounded[4]; besides, the devices they had concerns about for the most part are no longer in use.
AEDs cost anywhere from $3,000 to $4,000 per unit in 1997. They originally sold for $8,000 each.[11] So, the prices are half what they used to be. Grant programs are available for small agencies from the Prudential Insurance Company to offset purchase costs.[1] Among the predictions concerning AEDs are that their prices, as a result of mass production, will drop to somewhere between $500 to $800 and that they will be equipped with a cellular phone that could make the 911 call for you.[13] The AED is also getting smaller in size. Some AEDs are the size of an average paperback book or smaller. Perhaps they will be as small as a pocket pager someday.
PAD PROGRAMS FOR THE LAYPERSON
ACEP has prepared a Policy Resource and Education Paper (PREP) on AED programs.15 The Calgary (Canada) Fire & Rescue EMS/Fire PAD program is a private-public partnership. “Free of charge” training is given in the form of AHA Heartsaver CPR with added AED instruction. The devices are being placed in high-rise office buildings downtown and in City Hall. Dispatchers can tell the caller where the nearest AED is located[1] by consulting a database linked to their computer-aided dispatch (CAD) software. At the American Heart Association PAD II Conference, it was recommended that AED training be given to families of at-risk patients.[13]
Luhr, a privately owned medical training company, introduced its PAD Program in Houston, Texas, by volunteering to educate the public in CPR and AED. This program developed into a private-public partnership with local EMS authorities. Classes are free for community organization volunteers and “for a fee” for employees of local businesses and others who are reimbursed for the training.[13]
Security Guards
The Casino program of the Clark County Fire Department in Las Vegas has trained 700 security guards. This PAD program illustrates the importance of private-public partnerships between condo associations, security companies, property management companies, and local fire and EMS services. The Stratosphere, a Las Vegas casino, bought two AEDs because Mercy Ambulance Company, its local EMS agency, had found that 30 percent of all SCAs occurred on casino/hotel properties.[8]
The Calgary Fire & EMS Department in Canada trains security guards in its jurisdiction in basic cardiac life support, first aid, and special equipment (such as the AED). Their classes are four to eight hours. Additional topics may be bloodborne pathogens and patient lifting and carrying. An interesting finding while conducting this training was that people selected randomly were able to place an AED in service in the average time of a minute and a half even though they had not been trained in how to use the AED. These individuals were chosen while waiting for an elevator and asked if they would give a few minutes of their time to participate in the exercise. They were then presented with a “man down” scenario and instructed to use the AED. They read or listened to the instructions given to them by the machine and were able to deliver the first shock in the average time of a minute and a half. Trainees are evaluated six months after training to determine whether retraining is needed. AED retention was found to be actually better than CPR retention in this particular study.[1]
Grand Central Terminal in New York City, the largest-volume train station in the world (more than one-half million people use this facility each weekday) deployed an AED in July 1997. Less than 24 hours later, it was used successfully on a 42-year-old victim of SCA–a lawyer. In New York City, the survival rate for SCA is less than one percent (compared with the national average of five percent). The reason for this is that EMS cannot arrive early enough because of traffic congestion and high-rise buildings.16
Quantas Airlines no longer diverts its flights for a cardiac arrest victim. It uses the AED. If airline personnel get the patient back, it`s a save; if not, it`s a dead on arrival (DOA).[13]
“Large buildings/complexes may put a football field`s length between the fire department`s arrival at the front door and finally gaining access to a victim of SCA (10-11 minutes).”[1] Because of their poor call-to-shock times, shopping malls, airports (not just aboard airliners), train stations, stadiums, government complexes, and high-rise buildings are very good places for PAD programs.
Law Enforcement Officers and AEDS
In 1993 in Rochester, Minnesota, police officers were able to treat 31 patients of SCA with AEDs, resulting in 18 saves (58 percent). Police averaged one minute better in call-to-shock times compared with paramedics who had only a 43 percent survival rate for the same period.[1]
The Camden County, Georgia, Office of the Sheriff has implemented an AED program patterned after the Mayo Clinic`s (Rochester, Minnesota) study with the help of Kingsland Fire Rescue.17 This program is sponsored by the Mayo Clinic in Jacksonville, Florida. Rapid defibrillation by police can result in a high survival rate among out-of-hospital SCA victims.18
In some cases, police officers patrolling neighborhoods can access SCA victims much faster than EMS.[18] Some communities provide the U.S. DOT First Responder Training Program at their criminal justice academies. AHA Healthcare Provider CPR, or comparable training, is a prerequisite for first responder, which would provide for the addition of AED instruction as well.
Nurses and AEDs
In hospitals, general unit nurses are being trained in the use of AEDs, not just critical care nurses.19 Out of hospitals, why not train health department nurses, especially those working in the areas of adult health care and adult daycare?20 They are already taught CPR and ventilation with a bag valve mask with supplemental oxygen. Student nurses can learn to use an AED easily and quickly.21 Facilities such as nursing and retirement homes should be included in PAD programs as well. Areas with large retirement populations may find that as many as a third of out-of-hospital cardiac arrests may occur in centers or homes housing the elderly.
Many professional public safety organizations are proponents of PAD programs. It make sense to provide not just firefighters and EMS personnel, but also the lay public, with AEDs. These devices are becoming more commonplace because of their lower costs and more compact sizes.
Several studies conducted around the world prove that AEDs make a big difference. Some of those studies involved lay public users and first responders. Many lives have been saved, and many more can be saved (hundreds of thousands per year) if AEDs are placed not just on fire trucks and ambulances but also in places of mass gatherings, high-rise buildings, retirement/nursing homes, adult daycare facilities, and police cruisers.
It is highly imperative that PAD programs involve partnerships between fire departments, law enforcement, training institutions, AED manufacturers, and property management companies. Along with these private-public partnerships, changes in the law (local and federal) will promote growth of these programs. The future is very bright for public access defibrillation programs. AEDs are not just for firefighters and EMTs anymore.
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This jogger collapsed on the grounds of the local high school. After checking his pulse and completing endotracheal intubation, Arlington County (VA) firefighters prepare to implement automatic external defibrillation (AED). If the first defibrillation is delivered within 10 minutes, ventricular fibrillation, which kills 95 percent of sudden cardiac arrest victims, can be reversed. [Photo by Richard C. Slusher, Arlington County (VA) Fire Department.]
Endnotes
1. Spivak, M. “How AEDs are expanding field treatment for victims of sudden cardiac arrest,” Emergency Medical Services, 1998; 2:19-26.
2. “Public Access Defibrillation: A Statement for Healthcare Professionals from the American Heart Association Task Force on Automatic External Defibrillation.” AHA Medical/Scientific Statement, American Heart Association, 1995; 92:2763.
3. Cummins, R.O., R.D. White, P.E. Pepe. “Ventricular Fibrillation, Automatic External Defibrillators, and the United States Food and Drug Administration: Confrontation without Comprehension,” Annals of Emergency Medicine, 1995; 26(5):621-631.
4. Members of the ACEP`s EMS Committee include representatives of the National Association for EMTs, the Maternal and Child Health Bureau, Basic Trauma Life Support, the American Academy of Orthopedic Surgeons, Trauma Care and Injury Control, DOT-National Highway Traffic Safety Administration, the American Ambulance Association, the National Association of State EMS Directors, the International Association of Fire Chiefs, the Emergency Nurses Association, the National Association of EMS Physicians, the American Cardiac Society, and several state EMS programs.
5. ACEP. “Members, Liaisons, and Objectives,” EMS Committee, 1996-1998.
6. “Implementation of Early Defibrillation/Automated External Defibrillation,” Policy Statement, ACEP Board of Directors, 1992.
7. “Is There an AED in the First-Aid Kit? There May Be Soon,” Hewlett-Packard Company, 1994-1998. New survey reveals the AED a “must have” in police cars, fire trucks, and public buildings.
8. Graham, S., “Should Your Company Buy AEDs?” Safety & Health, 1997; 12,72.
9. “Overview: Automatic External Defibrillator (AED) Training,” Improving Fire Department Emergency Medical Services, International Association of Fire Chiefs, 1997, 4.
10. Automated External Defibrillation Training Course, EMP America, 1997. You`ll be ready to go once you`ve completed the AED program from EMP America, Inc.
11. Ezelle, P.A. “Making Use of Portable Defibrillators,” Occupational Health & Safety, 1997; (2),55-61.
12. Bocka, J.J., R. Swor, “In-Field Comparison Between Fully Automatic and Semi-Automatic Defibrillators,” Prehospital and Disaster Medicine, 1991; 6 (4):416.
13. Hudson, P. “Public access defibrillation ii: Summary and Comment,” Acute Care, Inc., 1997.
14. “Training Standards for Use of the Automated External Defibrillator by Non-Licensed or Non-Certified Personnel,” California Code of Regulations, Title 22, Division 9, Chapter 1.8, State of California, 1997.
15. “Implementation of Early Defibrillation/Automated External Defibrillator Programs,” Policy Resource and Education Paper, ACEP, 1996-1998
16. “Grand Central Terminal Deploys Life-Saving Technology to Treat Victims of Sudden Cardiac Arrest,” Product News, Merginet, 1997; 7.
17. “AEDs Hit the Streets of Camden County,” Office of the Sheriff 961212, Kingsland Fire and Rescue, 1996.
18. White, R.D., B.R. Asplin, T.F. Bugliosi, et al. “High Discharge Survival Rate After Out-of-Hospital Ventricular Fibrillation with Rapid Defibrillation by Police and Paramedics,” Annals of Emergency Medicine, 1996; 28:5:480-485.
19. Stewart, J.A., “Defibrillation Training for General Unit Nurses,” Journal of Emergency Nursing; 1992; 18:6, 480-485.
20. Stewart, J.A. “Beyond Code Teams: Early Defibrillation by Nurses for In-Hospital Cardiac Arrests,” Journal of Emergency Nursing; 1992; 18:6, 491.
21. Stewart, J.A., “Defibrillation by Nurses,” Resuscitation, 1994; 28:1, 71,72.
MICHAEL A. KONOZA, BS (EMS), NREMT-P, a career firefighter and paramedic since 1982, has been a member of the Arlington County (VA) Fire Department since 1988. He has been with the American Heart Association as a CPR instructor since 1983, as an ACLS instructor since 1992, and as a BLS instructor-trainer since 1997. Also, he has been a Virginia EMT instructor since 1994. Konoza is currently on the faculty of his alma mater, the George Washington University, Emergency Health Services program.
